BSHT Conflict of Interest Declaration Form

The British Society on Thrombosis and Haemostasis (BSHT) is committed to ensuring the integrity of its organisational, medical/scientific, programmatic and/or educational activities. BSHT’s policy requires disclosure of any commercial or other interest that might result in an actual, potential, or perceived conflict of interest by a member, researcher, contributor, and participant, in any BSHT activity. You are required to disclose any commercial/financial interest held by yourself, and your spouse or life partner in the last 12 months. This form must be submitted whether or not you have a relationship requiring disclosure.
 
Please indicate if you or any individual with whom you (or your spouse or life partner) directly share income has a relationship requiring disclosure, including.
 
Only interests that are related to the fields of thrombosis and hemostasis need to be disclosed. Include details in text boxes for each relevant conflict of interest.
BSHT Charity Number 282204
1.Current Employer(s)
2.Activities sponsored from a source that poses a potential conflict of interest. Academic consulting, membership on grant application review groups and honoraria.
3.Leadership Positions with decision-making influence in other medical/scientific organizations.
Currently serving as an Officer, Board member, Editor or Congress President or similar leadership positions with direct decision-making influence.
4.Speakers Bureau.
Currently participate on a speaking roster for an entity’s products or services (any amount).
5.Ownership Interest.
Including stock or stock options in a private or publicly traded entity but excluding mutual funds in any value.
6.Research Funding.
Sponsorship from a pharmaceutical or medical device company in any amount. Funding from government agencies and non-profit organizations is excluded from reporting here.
7.Other Honoraria.
Honoraria directly received from an entity (in any amount) excluding fees received for serving on grant application review panels (please declare these in ‘Activities sponsored from a source that poses a potential conflict of interest’) and excluding fees given as honoraria by another academic institution for an academic activity, such as seminars, grand rounds and postgraduate examinations.
8.Issued Patents and/or Licensed Inventions.
All patents and licensed inventions.
9.Any other interests/relationships.
Additional information regarding any relationships or commitments with other entities, including not-for-profit organizations.
10.I represent that the information reported above is accurate and complete.

I understand that, in the first instance, BSHT will only use this information for internal knowledge and will share it only with relevant BSHT Committee and Officers to assist in the avoidance of conflicts of interest.

I further understand that BSHT reserves the right to ask me not to participate in any Society activities or otherwise limit my participation in the particular BSHT activity/committee/elected or appointed position if the Society believes a significant conflict of interest exists that cannot be resolved and may have a negative impact on the Society.

Finally, I understand that failure to complete this “Conflict of Interest Disclosure Form” will disqualify me from participating in the affected activity. I further understand that the foregoing disclosure is to be considered a “living” document and I shall inform BSHT in a timely manner as appropriate/needed based on a change in my circumstances. 

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